1. Sternoclavicular joint dislocation Jason Blackham, MD Clinical Assistant Professor Division of General Internal Medicine University of Iowa Sports Medicine Center

2. History 17 yo high school quarterback was sacked during a game 17 yo high school quarterback was sacked during a game Complained of Complained of Right antero-inferior neck pain Right antero-inferior neck pain Dyspnea Dyspnea Dysphagia Dysphagia Unremarkable PMH Unremarkable PMH

4. Physical Exam RR 20, HR 84 RR 20, HR 84 Normal mentation and no resp distress Normal mentation and no resp distress Neurological exam normal Neurological exam normal Pain with palpation of right clavicle Pain with palpation of right clavicle Loss of fullness of proximal clavicle Loss of fullness of proximal clavicle No skin tenting No skin tenting

5. Physical Exam Walked off the field Walked off the field Postured with head tilted (R), arm at side in IR with elbow at 90 degrees flexion Postured with head tilted (R), arm at side in IR with elbow at 90 degrees flexion Off field exam Off field exam Trachea midline, no stridor Trachea midline, no stridor Breath sounds normal, symmetric, resonant Breath sounds normal, symmetric, resonant No cardiac murmer or rub and symmetric pulses No cardiac murmer or rub and symmetric pulses Transported to ED Transported to ED

6. Differential Diagnosis Shoulder dislocation Shoulder dislocation Proximal clavicular fracture Proximal clavicular fracture Sternoclavicular joint dislocation Sternoclavicular joint dislocation Traumatic pneumothorax Traumatic pneumothorax

9. T C C AF R BV BA E BV

16. Diagnosis Posterior sternoclavicular joint dislocation with avulsion fracture Posterior sternoclavicular joint dislocation with avulsion fracture

17. Closed Reduction

20. Treatment Reduction under general anesthesia Reduction under general anesthesia 4 weeks immobilized in sling 4 weeks immobilized in sling 2 weeks of protected ROM, strengthening 2 weeks of protected ROM, strengthening Cornerback for 3 weeks Cornerback for 3 weeks Returned to quarterback at 9 weeks Returned to quarterback at 9 weeks

21. Epidemiology 40% MVC 40% MVC 21% Sports 21% Sports 39% Other Trauma 39% Other Trauma ~3% of all shoulder girdle injuries > 90% anterior dislocations Clin Sports Med 2003;22:387-405 Phys Sports Med 1999;27(2):105-13

22. Mechanisms

23. Mechanisms of Posterior Fall on shoulder with arm flexed and adducted Fall on shoulder with arm flexed and adducted Lateral force to shoulder when shoulder rolled forward Lateral force to shoulder when shoulder rolled forward Posterolateral force to shoulder while opposite shoulder on ground Posterolateral force to shoulder while opposite shoulder on ground Force to anteromedial clavicle Force to anteromedial clavicle Clin Sports Med 2003;22:387-405 Military Med 2004;169(2):134-6 Rockwood and Green’s Fractures in Adults. 1997

24. Complications of Anterior SC joint arthritis SC joint arthritis Cosmetic appearance Cosmetic appearance Persistent prominence Persistent prominence Chronic pain Chronic pain Recurrent instability Recurrent instability

25. Complications of Posterior Pneumothorax Pneumothorax Compression or laceration Compression or laceration Trachea Trachea Esophagus Esophagus Artery / Vein Artery / Vein SVC laceration SVC laceration Brachial plexus injury Brachial plexus injury Thoracic outlet obstruction Thoracic outlet obstruction J Trauma 1998;44(2):381-3 Clin Sports Med 2003;22:371-85

26. Treatment of Anterior Anterior Dislocation Anterior Dislocation Controversial Controversial Majority unstable following reduction Majority unstable following reduction Sling immobilization for 6 weeks Sling immobilization for 6 weeks If continued symptoms, surgery If continued symptoms, surgery

27. Treatment of Posterior Recommendation is for closed reduction Recommendation is for closed reduction <48 hrs to <7 days of injury <48 hrs to <7 days of injury Sling or figure-of-eight Sling or figure-of-eight Single review article & case studies Single review article & case studies good results good results If unstable or complications, then open If unstable or complications, then open Clin Sports Med 2003;22:359-70 Clin Sports Med 2003;22:387-405 Can J Surgery 1986;29(2):104-6 J Trauma 1967;7(3):416-23

28. Return to Play Sling or figure-eight harness for 4-6 weeks Sling or figure-eight harness for 4-6 weeks Return when pain free motion Return when pain free motion may require additional 4-8 weeks may require additional 4-8 weeks Military Med 2004;169(2):134-6 Phys Sports Med 1999;27(2):105-13

29. Operative Treatment Claviculectomy Claviculectomy Resection of medial clavicle Resection of medial clavicle Reconstruction of capsule or ligaments Reconstruction of capsule or ligaments Not pinning Not pinning Migration of transfixion pins Migration of transfixion pins

30. Operative Treatment Capsule repair with tendon graft Capsule repair with tendon graft Burrow’s procedure Burrow’s procedure Sublcavius tendon tenodesis Sublcavius tendon tenodesis Fascia lata graft Fascia lata graft Sternocleidomastoid muscle Sternocleidomastoid muscle Medial clavicle osteotomy Medial clavicle osteotomy

31. Outcome Completed FB season without pain or instability Completed FB season without pain or instability Pitched for high school baseball team Pitched for high school baseball team

32. Summary Posterior SC dislocations are rare Posterior SC dislocations are rare Potentially severe complications Potentially severe complications Closed reduction is preferred Closed reduction is preferred RTP after healing and ROM regained RTP after healing and ROM regained generally 6-14 weeks generally 6-14 weeks